Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda

BMC Research Notes, Jun 2018

Objective To determine frequency of palatal fistula following primary cleft palate repair and the associated factors as a measure of cleft palate repair outcome and its challenges at a cleft centre in Uganda. Results Between May and December 2016, 54 children with cleft palate were followed up at Comprehensive Rehabilitation services of Uganda (CoRSU) hospital, from time of primary cleft palate repair until at least 3 months postoperative to determine whether they developed palatal fistula or not. Frequency of palatal fistula was 35%. Factors associated with increased fistula formation were cleft width wider than 12 mm (p = 0.006), palatal index greater than 0.4 (p = 0.046), presence of malnutrition at initial outpatient assessment (p = 0.0057) and at time of surgery (p = 0.008), two-stage palate repair (p = 0.005) and postoperative infection (p = 0.003). Severe clefting (palatal index greater than 0.4) was seen in 74% of patients and malnutrition (Low weight for age) seen in 48% of patients. Palatal fistula rates at our institution were high compared to reports in literature. The high proportions of severe clefting and malnutrition observed in our population that was also poor and unable to afford feeding supplements increased likelihood of fistula formation and posed challenges to achieving low fistula rates in our setting.

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Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda

Katusabe et al. BMC Res Notes Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda Josephine Linda Katusabe 0 Andrew Hodges 0 George William Galiwango 0 Edgar M. Mulogo 0 Comprehensive Rehabilitation Services Uganda (CoRSU) Hospital , P.O.Box 46, Kisubi , Uganda Objective: To determine frequency of palatal fistula following primary cleft palate repair and the associated factors as a measure of cleft palate repair outcome and its challenges at a cleft centre in Uganda. Results: Between May and December 2016, 54 children with cleft palate were followed up at Comprehensive Rehabilitation services of Uganda (CoRSU) hospital, from time of primary cleft palate repair until at least 3 months postoperative to determine whether they developed palatal fistula or not. Frequency of palatal fistula was 35%. Factors associated with increased fistula formation were cleft width wider than 12 mm (p = 0.006), palatal index greater than 0.4 (p = 0.046), presence of malnutrition at initial outpatient assessment (p = 0.0057) and at time of surgery (p = 0.008), two-stage palate repair (p = 0.005) and postoperative infection (p = 0.003). Severe clefting (palatal index greater than 0.4) was seen in 74% of patients and malnutrition (Low weight for age) seen in 48% of patients. Palatal fistula rates at our institution were high compared to reports in literature. The high proportions of severe clefting and malnutrition observed in our population that was also poor and unable to afford feeding supplements increased likelihood of fistula formation and posed challenges to achieving low fistula rates in our setting. Cleft palate; Primary palate repair; Palatal fistula Introduction Palatal fistula is a failure of healing or breakdown in the primary surgical repair of a cleft palate [ 1 ]. Palatal fistula results in persistent communication between oral and nasal cavities leading to unpleasant symptoms such as nasal spillage of feeds, hypernasal speech, articulation problems which undermine the success of palate repair [ 2 ]. A low incidence of palatal fistula is one of the indicators of successful cleft palate repair [ 3 ]. Incidence of palatal fistula in literature ranges from 0 to 35% [ 1, 3–8 ] with overall incidence of 8.6% reported by a meta-analysis of studies in Europe, America, Asia and Africa [ 9 ]. Risk factors of palatal fistula reported include type of cleft, cleft palate width, surgeon’s experience, timing and technique of repair. There is a paucity of studies in Africa and Uganda assessing frequency of palatal fistula and associated factors following cleft palate repair. In Uganda, reports show that most children with cleft palate are already malnourished when they first present to hospital and may continue failing to thrive if no timely intervention is done [ 10–12 ]. Effect of this malnutrition on surgical outcome of palate repair has not been studied. Our study aimed to determine frequency of palatal fistula following primary palate repair and the associated factors at CoRSU hospital in order to assess our cleft palate repair outcome and also establish the challenges to achieving low fistula rates. Main text Methods A prospective case series was conducted from May to December 2016 at CoRSU hospital, a specialized hospital in Uganda offering free cleft palate surgery. Children with unrepaired cleft palate, whose caregivers gave written consent to participate in the study were enrolled and followed up from time of primary cleft palate repair until at least 3  months postoperative to determine whether they developed palatal fistula or not. Primary palate repair (surgery on cleft palates that have not been repaired before) was performed either as single-stage repair of both hard and soft palate or as a two-stage procedure involving hard palate repair with vomer flap in first stage and soft palate repair 3 months later in second stage. Surgical techniques included intravelar veloplasty for soft palate, Von Langenbeck flaps, Bardarch flaps and Hybrid flaps for hard palate (see Additional file 1 showing description of surgical techniques). Desired perioperative information including age, weight and length, type of cleft, type of surgery, surgical technique and surgeon’s experience (based on volume of palate surgeries performed annually) was recorded in pretested data forms. Preoperative dental casts of each palate were made, from which cleft width and palatal shelf widths were measured using Castroviejo calipers (see Additional file  2 showing dimensions measured). Weight for length and weight for age z-scores were calculated and compared with W.H.O reference values to determine nutrition status. At postoperative review, a consultant plastic surgeon inspected the palate using a clinical torch and tongue depressor to determine presence or absence of fistulas. Only fistulas posterior to incisive foramen were considered. Statistical a (...truncated)


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Josephine Linda Katusabe, Andrew Hodges, George William Galiwango, Edgar M. Mulogo. Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda, BMC Research Notes, 2018, pp. 358, Volume 11, Issue 1, DOI: 10.1186/s13104-018-3459-6